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Fees(must accompany form): <br /> Burnett County Subdivision Permit/Survey Review Subdivision w/o Survey: $50.00 <br /> Survey of Existing Parcel: $50.00/lot <br /> Application and/ocr� Pre-Application Form Subdivision w/Sutvev: $200.00+$50.00/lot <br /> Owner: Gt t i m���Q1y kGl C(1't GLC�� Buyer: .p <br /> Address:Qo(9`1 Koiay1(W ed Address: <br /> Siren IA)Z 548r)- <br /> /�)i5 6) l' � <br /> Phone: Phone: .� <br /> Original Parcel Information <br /> Q <br /> Parcel ID#:Q - p(7 ,•;3$-/'7-a2-4-Q3 ppo- 6//O 60 Section 0a Township 5s Range l7 <br /> O <br /> Original Description(or attach copy): S V.) Is <br /> Current Zoning: A 'a Floodplain Y/N: (J Wetlands Y/N: A/ Lake/River Class: <br /> eName of Water Body: tl�(j t1.d.✓l" Shoreland Agreement/SIPS Y(N:_,h) <br /> . \ i <br /> Farmland Preservation Y/N: Iv Managed Forestry Law Y/N: i <br /> New Parcel Information F <br /> Proposed New Legal Description and Parcel Size: <br /> SC W `la. SW se- <br /> Acresjo ta-V S <br /> (If parcel is to be surveyed,provide preliminary map. See attached for preliminary map requirements.) <br /> Proposed access to public road: Lc?1C"Glk'- d <br /> A <br /> Proposed access to public waters to be provided Y/N: - •• <br /> l <br /> If yes,describe access: <br /> De <br /> Signature of Owner: Date: <br /> Signature of Owner: Date: <br /> c <br /> Does parcel meet Zoning Requirements? Yes No <br /> o ➢ Does parcel require a Survey? Yes No n <br /> �L. J <br /> 7 <br /> 00 ➢ Permit application fees submitted? ❑ Amount$JPO O G Receipt# o <br /> I v <br /> m econciles with Real Property Lister `Yes No Date: <br /> c <br /> If not,explain: <br /> o W <br /> c '4Z <br /> y tT <br /> Vj <br /> Applicatio Approved Denied Reason for Denial: o <br /> b <br /> Land Use: Date: <br />